Colonial Nursing and Rehabilitation Center

Inspectors wroteBased on facility policy review, record review, and interview, the facility failed to provide adequate assistance to prevent falls for 1 of 3 residents sampled for falls (Resident (R) 14).

Inspectors wroteBased on observation, interview, record review and review of a manufacturer's instructions, the facility failed to ensure licensed nursing staff demonstrated competencies and skill set necessary to administer insulin via insulin injector pen for one (Licensed Practical Nurse (LPN) of two licensed nurses observed during the medication administration task for one of 11 residents observed during medication administration (Resident (R) 50).

Inspectors wroteBased on observation, interviews, record review, and review of the facility's policy, it was determined the facility failed to provide residents with appropriate care and services to ensure residents were free from neglect for one (1) of sixteen (16) sampled residents (Resident #18). Record review revealed the facility admitted Resident #18 on 12/10/2023 and assessed the resident as having an unstageable pressure injury to his/her right heel. However, there were no orders in place for wound care or monitoring until 01/15/2024. The facility's failure to follow its policy related to providing care for the resident's wound, after being admitted with an unstageable pressure injury, deprived the resident of his/her health care needs and created a situation which prevented the resident's wound from healing. [...]

Inspectors wroteBased on interview, record review and review of facility policy, it was determined the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for two (2) of sixteen (16) sampled residents (Resident #18 and Resident #195). Although the facility admitted Resident #18 on 12/10/2023, and assessed the resident as having a right heel unstageable Deep Tissue Injury (DTI) on that date (with no measurement of the wound), the facility did not develop a Baseline Person-Centered care plan for Skin Integrity until 12/26/2023, sixteen (16) days following admission. [...]

Inspectors wroteBased on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (1) of three (3) residents reviewed for pressure out of sixteen (16) sampled residents (Resident #18). The facility admitted Resident #18 on 12/10/2023 and assessed the resident on that date as having a right heel unstageable Deep Tissue Injury (DTI). However, there was no documented evidence of a wound evaluation to include further description or a measurement of the right heel pressure injury on admission. [...]

Inspectors wroteBased on interviews, record reviews, and review of facility's policy, it was determined the facility failed to ensure residents had the right to formulate an advance directive for nine (9) of sixteen (16) sampled residents (Residents #7, #8, #15, #17, #145, #195, #32, #295, and #18). Review of the residents' medical records revealed there was no documented evidence to support the facility provided a written description of the facility's policies that would empower the residents to participate in their own health care and decision-making by formulating an advance directive. [...]

Inspectors wroteBased on observation, interview, record review, review of the facility's assessment, and review of the facility's policy, it was determined the facility failed to provide adequate staff to provide nursing and related services. Review of Resident Council Meeting Minutes revealed resident's voiced concern that call lights were not answered timely. Additionally, resident's were concerned there was not enough staff on the night shifts and weekends.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure standard and Enhanced Barrier Precautions were followed. Observation during initial tour of the facility, on 01/23/2024 starting at 8:45 AM, revealed there were no residents on Enhanced Barrier Precautions. However, observation on 01/24/2024 starting at 8:50 AM, revealed the North and South Halls, had nineteen (19) resident rooms with EBP signage, and two (2) Personal Protective Equipment (PPE) bins on the halls. [...]

Inspectors wroteBased on observations, interviews, and review of the facility's policy it was determined the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for three (3) of sixteen (16) sampled residents (Resident's #295, #195, and #17). Observations of Resident #295 and Resident #17, on 01/24/2024 and 01/25/2024, revealed the resident's catheter bags had no dignity cover in place. Observation during a lunch meal on 01/23/2024, revealed Resident #195 waited thirty-two minute for his/her meal tray, while other residents had been served their food in the dining room.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to review and revise the care plans when changes occurred for one (1) of sixteen (16) sampled residents (Resident #18). On 01/25/2024, Resident #18 was assessed to be unable to transfer independently and was unable to stand or pivot with transfer. It was at that time, the resident required the use of the total body lift with the assistance of two staff for transfers. The facility; however, failed to ensure the resident's Comprehensive Care Plan was updated/revised to reflect the change in the resident's assessed needs.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals for one (1) of three (3) closed records (Resident #43). Review of Resident #43's closed record revealed there was no documentation to support the facility had developed a discharge plan for the resident upon admission. Further, the Social Service Director (SSD) stated she did not know how the resident's discharge plan was missed.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide the necessary care and services to ensure the residents had an effective communication system for one (1) of sixteen (16) sampled residents (Resident #30). Observation and an attempted interview with Resident #30, who was a Non-English speaking resident, on 01/23/2024 at 9:00 AM, revealed the resident was unable to communicate with the State Survey Agency (SSA) Surveyor due to not having access to a functioning communication system/device.

Inspectors wroteBased on observation, interview, and Reivew of the facility's policy, it was determined the facility failed to ensure residents were able to exercise their right to view the results of the facility's State Survey results and Plan of Correction. Additionally, the facility failed to ensure residents and/or family members were aware of the location of the survey results and/or the results were not easily accessible to them. Observations on 01/23/2024 through 01/26/2024, revealed the survey results were not readily accessible to residents, family members, and legal representatives of the residents. The survey result binder was located in the facility's front lobby but was not accessible to residents without staff assistance.